Playing Doctor

If you're committed to the idea that decision making should be logical, scientific, and fact-based, it can be frustrating to look at decisions that come out of the political process. Why do our elected officials do the things they do? It's usually hard to know. There are always reasons that politicians will talk about and the reasons they won't. Often enough, there are also reasons they seem not to have thought of—which often seem to be the most relevant of all.

Here's what I'm talking about. Late in June, the House of Representatives passed a big health and education spending bill. Included in it was an amendment to ban Viagra (sildenafil) and other similar drugs for erectile dysfunction from reimbursement under Medicare and Medicaid.

The stated reason was straightforward. "We don't force taxpayers to pay for face lifts, weight-loss drugs, hair-growth treatment or vacations, so we should not force them to pay for sexual-performance drugs," Representative Steve King (R-IA) told the Washington Post. "Medicare and Medicaid were established to provide lifesaving medication for the truly needy."

It may be straightforward, but it doesn't actually make sense. If the point is to limit Medicare and Medicaid to lifesaving medications, then lots of other things ought to be banned—pain meds, SSRIs, anti-arthritics, and even a lot of antibiotics that treat conditions that are debilitating but not fatal.

And if the point is to include under Medicare and Medicaid only drugs that answer legitimate problems, then ED drugs, which treat the effects of diseases such as diabetes and prostate cancer, should qualify at least part of the time. Indeed, there is reason to think that by counteracting sexual side-effects of treatments, ED drugs help patients be more compliant to lifesaving therapies. Is that the same thing as a vacation?

So why single out the ED drugs? I imagine that individual congressmen are responding to a whole range of issues. Some are no doubt focusing on cost; no one really knows what the tab for the Medicare drug benefit will be, but it's safe to predict that almost everyone will think it's too high. That goes double in the unlikely event that the states actually succeed in their fight against the "clawback" provisions of the Medicare Modernization Act, and push costs back to the federal government.

There are more, of course. People are angry over the revelation that Medicaid paid for ED drugs for some sex offenders. The constant barrage of advertising—especially e-mail solicitations from shady Internet companies—underscores the idea that ED drugs are more about fun than treatment. And some Medicaid participants, of course, have played a significant role in diverting prescription drugs into illegal channels.

I'd argue that if you actually got congressmen to sit down and work through all the nuances, they'd still back the ban, but the reason would be more like this: "We don't mind paying for medical uses of ED drugs, but we've got no faith that they'll be appropriately prescribed. For that to happen, drug companies, doctors, and patients would all have to cooperate, and we don't really trust any of them. We could impose controls, but they'd cost too much, and we couldn't believe in them either."

Why bother to second-guess Congress? The main reason is that their stated reason was so weak that there's no way to respond. The issue of the integrity of the prescribing process is something we might actually be able to do something about. And it points out a real flaw in the Medicare prescription drug plan—one that could bring the program down. If Congress wants to play doctor with Medicare, maybe it should start there. After all, like the man said, lifesaving should take precedence over the purely cosmetic.